Technology for Eating Disorders: The Major Players

By: Melissa Gerson, LCSW
Over the past 10 years, various universities, researchers and clinical teams have worked to evaluate the efficacy and efficiency of eating disorder treatments delivered via technology. In this time, a wide range of technologies (e.g., televideo, e-mail, CD-ROM, Internet, text message) have been utilized with the intention of either delivering a treatment modality entirely, or serving as a compliment to a specific level of care (e.g., therapy, guided self-help, treatment adjunct). These studies were typically based off cognitive behavioral principles and interventions (CBT) and utilized a sample size of at least 10. While the studies demonstrated an overall positive result, caveats remain and are worth evaluating prior to implementing such services in any practice. The predominant concern that was shared between researchers and clients was a desire for more personal and face-to-face interaction. Despite this desire, technology continues to grow at an extremely fast rate and it is necessary to evaluate this rich area for growth and development within the field of mental health. Let’s review a few of the identified ‘major players’ within this pool of research.

Those seeking to attain the highest degree of integration between psychotherapy practice and technology would utilize devices such as the telephone, e-mail, and videoconferencing. These devices are the most direct, meaning they administer actual psychotherapy. Studies surrounding these devices posed questions that would evaluate the acceptability of these formats for both the administrator and the recipient. A number of factors must be considered when utilizing an email or internet based format such as access to a computer and internet-based education.

Email Format:

The first technology-based innovation in a large scale trial was to contact a large number of potential patients by email through mass mailings. The therapists used e-mail to elicit history, encourage food monitoring, and identify and change maladaptive ED cognitions and behaviors.

The e-mail treatment lasted three months and averaged two e-mails per week. Researchers stated “At the end of treatment, significantly fewer individuals met criteria for an ED in the e-mail condition (~22%) compared with the wait-list control group, of which all members were still diagnosed with an ED at follow-up.”

The email format demonstrated a new means to reach a large group of people who may not otherwise seek treatment or have access to an ED clinic in their geographic region.

Internet Format:

A second internet-based format utilized an internet-based therapy called “Set Your Body Free,” (Gollings & Paxton, 2006). Regardless of designated format, each participant received the treatment manual that provided focused psychoeducation, change-based strategies and a treatment topic guide. Participants in the Internet-based condition involved synchronous (scheduled, real-time, two-person) communication were paired with a therapist in an online chat-room with discussion board (“chats” included a patient's motivation to change, self-monitoring skills, degree of body dissatisfaction and more). At the end of the study, subjects in both conditions reported reduced ED symptoms (e.g., self-reported body image concerns, dietary restraint, and bulimic symptoms). While there were stronger initial effects in the face-to-face condition, participants in the Internet group continued to make gains, reaching similar levels of symptom reduction at 6 months follow-up.

It is important that researchers fully explored limitations of this study, and factors that may have impacted patient experience and results. These were identified as “participants’ keyboard skills, which may have reduced some individuals’ participation, difficulties in relaying the same amount of information as in traditional talk therapy, and computer problems that resulted in four participants’ premature termination.”

Video-conferencing (Telehealth)

A fourth study evaluated face-to-face intervention as compared to the use of video-conferencing. This technology-supported therapy condition attempted to replicate the experience of traditional psychotherapy more closely. Results indicated similar levels of ED symptom reduction in the two groups and equivalent therapist alliance in both conditions. Interestingly, therapists reported a subjective preference for the FTF format. Reasons cited included that therapists valued the experience of sharing a room with a client as the communication results in greater feelings of closeness between individuals and traditionally, psychiatrists and psychologists consider face-to-face contact necessary to fully assess the general mental (and physical) state of the patient’s heath. Additional barriers included a difficulty scheduling sessions at distal sites and technical difficulties.

Guided Self Help:

In a research study that utilized internet-based guided self-help sites/manuals/CD-Roms, “more than one-third of the BED sample reported abstaining from binge eating post-intervention and showed significant improvements in related ED symptoms such as shape concerns and body dissatisfaction.” While outcomes suggest that Internet-based guided self-help holds promise to benefit patients who have difficulty accessing face-to-face psychotherapy, issues with treatment completion and with suboptimal response require additional attention. To remedy this, a set of research studies investigating guided self-help programs have also included additional contact between counselors and participants, with the aim of boosting the therapeutic alliance, promoting retention, and increasing effect.

While generally, technology-delivered therapies have yielded positive results, interventions with the greatest level of therapist interaction resulted in higher abstinence rates. These findings suggest that there may be an ‘optimal level’ of therapist-client interaction that results in the highest rate of long-term symptom reduction. Researchers will continue to dive further into this field to identify what that necessary level of support is, and how to promote substantial and permanent behavioral change via the promise of technology.

Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, the leading outpatient eating disorder treatment center in New York City. Melissa is a native New Yorker whose “first career” was as a professional ballet dancer with the Miami City Ballet in Florida. After seven years, touring with the MCB company, Melissa retired from ballet and returned to her NYC roots to attend Columbia University as a Psychology major. She went on to earn a master's degree in social work at New York University. Melissa has over a decade of training and experience in treating eating disorders. She completed post-graduate training at some of the most reputable NYC institutions like NYU’s Psychoanalytic Institute, the William Alanson White Institute and NY State Psychiatric Institute. Melissa is a true leader in the eating disorder treatment community with a particular focus on using the most current and efficient evidence-based treatments like CBT-E, DBT and Family-Based Treatment for Children and Adolescents.